NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
Question 2 of 5
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings should the nurse report immediately?
Correct Answer: A
Rationale: Hypotension (90/60 mmHg) is a serious carvedilol side effect, risking perfusion in heart failure. Options B, C, and D are normal.
Question 3 of 5
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse, and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
Question 4 of 5
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, a serious side effect of carvedilol, risking reduced perfusion in heart failure. Options B, C, and D are normal: heart rate 70 bpm, respiratory rate 18 breaths/min, and oxygen saturation 95% are stable.
Question 5 of 5
A middle-aged woman is brought to the emergency room after being raped in her home. The client asks the nurse to call her husband to come to the emergency room. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?
Correct Answer: D
Rationale: sexual assault by rape is a crisis situation for both victim and family members and friends